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Is A Biopsy Necessary To Diagnose Kümmell’s Disease?

 Colaris J W*, Coene L N J E M*

* Department of Orthopaedic Surgery,HAGA Hospital,Sportlaan 600,2566 MJ,The Hague,The Netherlands

Address for Correspondence:

J.W. Colaris, MD
Department of Orthopaedic Surgery
HAGA Hospital,Sportlaan 600,2566 MJ
The Hague,The Netherlands
Fax-number: 0031703592089
Telephone-number: 0031642220265 / 0031703921320


We report on the case of a 31-year-old man with pain in the thoracic spine caused by a kick during soccer. Based on typical radiological features, i.e. a vacuum cleft phenomenon and a higher density of the vertebral body of T7, which matched the clinical findings, i.e. the preceding trauma and the characteristic level of the painful vertebra, the diagnosis Kümmell’s disease was made. The typical collapse of the traumatised vertebral body, as to be expected in Kümmell’s disease, failed to appear. Further examination revealed a primary lung-carcinoma with several metastases, including vertebra T7. There is no consensus how to diagnose Kümmell’s disease. This case report illustrates that even if radiological and clinical features are typical of Kümmell’s disease, it is necessary to confirm the diagnosis with a biopsy.

J.Orthopaedics 2007;4(3)e13

Kümmell’s disease; vertebral osteonecrosis

In 1891, the German surgeon Hermann Kümmell first described a patient with a delayed collapse of a traumatised vertebral body.1-4 Since then this rarely reported and poorly understood phenomenon is called Kümmell’s disease.2,3  It is caused by osteonecrosis of a vertebral body,  probably due to a decreased blood-supply after trauma.1-4  The clinical presentation will typically be a male of middle age with backache after a minor trauma. An asymptomatic period will usually follow. After weeks to months, osteonecrosis of the vertebral body predictably results in a collapse, which causes severe pain. Kyphotic deformity and neurologic symptoms may then occur.1,3,4 The initial radiograph of the spine usually doesn’t show a fracture of the traumatised vertebral body.2,3 On later radiographs and CT-imaging the intravertebral vacuum cleft phenomenon (an accumulation of gas in a vertebral body) combined with a subcortical fracture and hyperdensity of the vertebral body, are typical for Kümmell’s disease.1,2,4    On MR images the intravertebral gas is of low signal intensity on all sequences. Although relatively non-specific, a bone-scan shows early activity.3,4

Histopathology demonstrates spongiosa with multiple haemorrhages, atrophy of the bony framework, multiple microscopic fractures, inflammatory changes and paravertebral fibrosis.1,4

Case Report :

A healthy 31-year-old man was seen for evaluation of persistent backache after a kick in his back during a game of soccer two months previously. Physical examination only revealed pain at the level of vertebra T7. Radiographs and CT-imaging showed the following changes of the vertebral body of T7: A higher density of the vertebral body, a small collapse of the upper endplate, a subcortical fracture and intravertebral accumulation of gas (vacuum cleft phenomenon) (figures 1 and 2). 







Figure 1: X-ray of T7







Figure 2: Computed Tomography of T7

(Radiograph and CT-imaging show the following changes of the vertebral body of T7: A higher density of the vertebral body, a small collapse of the upper endplate, a subcortical fracture and intravertebral accumulation of gas (vacuum cleft phenomenon). )

Based on the history, clinical examination and these very typical radiological features the diagnosis Kümmell’s disease was made. The orthopaedic surgeon prescribed a thoracic brace. During the following months the pain diminished and the radiographs taken at two weeks interval showed no further deterioration of the vertebral body T7. Four months after the first visit, only slight pain persisted. The patient however developed a painful sacroiliac joint on the right side. A radiograph of the pelvis showed an osteolytic lesion of the right os ilium. A total body bone scan demonstrated an extensive amount of hotspots throughout the whole skeleton. An extensive blood-examination demonstrated numerous abnormalities due to bone metastasis.

A CT-scan showed a tumour in the upper lobe of the right lung as well as osteolytic and osteosclerotic lesions in several vertebral bodies, which were (even retrospectively) not visible on the x-rays taken earlier. A biopsy of the os ilium revealed a metastasis of a primary lung-carcinoma.

Discussion :

Several authors wrote about the intravertebral vacuum cleft phenomenon as typically for Kümmell’s disease. Maldague et al 5 first described the intravertebral vacuum cleft phenomenon in 1991. They and others authors 6 advocate this phenomen to be pathognomic for Kümmell’s disease or other cases of spontaneous vertebral osteonecrosis. Bhalla et al 6 conclude that recognition of the near-certain benign significance of a linear intravertebral gas collection revealed by radiography may prevent unnecessary imaging or biopsy in a patient with a suggestive vertebral compression deformity.

The radiological features of the intravertebral vacuum cleft sign in Kümmell’s disease differ according to several authors. Osterhouse et al 7 demonstrated the dynamic entity of the intravertebral vacuum in Kümmell’s disease, which is subject to changes in size and shape. Others found correlation between shape of the vacuum and its benign or malignant character. 8 While these authors wrote about the typical vacuum cleft phenomenon in Kümmell’s disease, Dupuy et al 9 demonstrated atypical fluid collections in vertebral fractures with avascular necrosis. 

Articles report about intravertebral gas and fluid collections in osteoporotic fractures. Lafforgue et al 10 hypothesize that the vacuum sign could simply be the result of migration of an intradiscal gaseous collection through the fractured endplate of some osteoporotic collapses. Mirovsky et al 11  found a vacuum sign within 26 of 101 osteoporotic vertebral fractures in a retrospective research. They reject the vacuum sign as pathognomic for Kümmell’s disease. The correlation of vacuum sign with fracture non-union was made in this article.

McKiernan et al 12  also demonstrate intravertebral clefts in osteoporotic vertebral fractures. They found these radiological features indistinguishable from Kümmell’s disease. Baur et al 13 described the displacement of intravertebral gas by fluid in cases of osteoporotic fractures. Naul et al 14 also described five patients with plain radiographic evidence of a compressed vertebra containing an intravertebral vacuum cleft. While these articles demonstrate the occurrence of intravertebral gas in Kümmell’s disease and osteoporotic fractures of the vertebra, several articles have been published about the combination of intravertebral gas and malignancy. Kumpan et al 8  presented a case of intraosseous vacuum in a malignant vertebral collapse. Baur et al 13 described the displacement of intravertebral gas by fluid in cases of neoplastic fractures. A case-report shows a metastatic Ewing’s sarcoma involving the vertebral spine and mimics Kümmell’s disease.15

Some authors believe that gas within a vertebral body is even not diagnostic for osteonecrosis, osteoporotic fractures or neoplasm. They advise us also to differentiate between spinal infection, degenerative cysts and Schmorl’s nodes.  

In this patient with backache, we rejected the diagnosis of a degenerative cyst and an osteoporotic fracture because of his age. The clinical appearance was not suggestive for an infectious cause. To make a differentiation between Kümmell’s disease and a metastasis, a biopsy was recommendable.


It is important to be aware of the existence of neoplastic metastasis, which mimics the clinical and radiological features of Kümmell’s disease. With the fast development in radiological equipment, a vertebral biopsy becomes less invasive with very few complications. The described case, strengthened by several articles, demonstrates the importance of confirming the diagnosis of Kümmell’s disease with a biopsy. 

Reference :

  1. Brower A, Downey E.  Kümmell disease: Report of a case with serial radiographs. Radiology 1981; 141: 363-364.

  2. Hermann G, Goldblatt J, Desnick R. Kümmell disease: delayed collapse of the traumatised spine in a patient with Gaucher type 1 disease. The British Journal of Radiology 1984; 57: 833-835

  3. Van Eenenaam P, El-Khoury G. Delayed post-traumatic vertrebral collapse (Kümmell’s disease): Case report with serial radiographs, computed tomographic scans and bone scans. Spine 1993; 18: 9: 1236-1241

  4. Young WF, Brown D, Kendler A, Clements D. Delayed post-traumatic osteonecrosis of a vertebral body (Kümmell’s disease). Acta Orthopaedica Belgica 2002; 68: 1

  5. Maldague BE, Noel HM, Malghem JJ: The intravertebral vacuum cleft: a sign of ischemic vertebral collapse. Radiology 1978, 129: 23-29

  6. Bhalla S, Reinus WR. The linear intravertebral vacuum: a sign of benign vertebral collapse. American Journal of Roentgenology 1998; 170: 6:1563-9

  7. Osterhouse MD, Kettner NW. Delayed post-traumatic vertebral collapse with    intravertebral vacuum cleft: a case report. Journal of Manipulative and Physiological Therapeutics  2002; 25: 4: 270-5

  8. Kumpan W , Salomonowitz E , Seidl G. The intravertebral vacuum phenomenon . Skeletal Radiology 1986; 15 : 444 – 7

  9. Dupuy DE, Palmer WE, Rosenthal DI. Vertebral fluid collection associated with vertebral collapse. Am J Roentgenology 1996; 167: 1535-1538

  10. Lafforgue P, Chagnaud C, Daumen-Legre V. The intravertebral vacuum phenomenon. Migration of intradiscal gas in a fractured vertebral body? Spine 1997; 22: 16: 1885-1891

  11. Mirovsky Y, Anekstein Y, Shalmon E, Peer A. Vacuum Clefts of the Vertebral Bodies. Am. J. Neuroradiology 2005; 1: 26: 7: 1634 – 1640

  12. McKiernan FE, Faciszewski , T. Intravertebral Clefts in Osteoporotic Vertebral Compression Fractures . Arthritis & Rheumatism 2003; 48: 5: 1414 – 1419

  13. Baur A, Stabler A, Arbogast S. Acute osteoportoic and neoplastic vertebral compression fractures: Fluid sign at MR Imaging. Radiology 2002; 225: 3: 730-735

  14. Naul LG, Peet GJ, Maupin WB. Avascular necrosis of the vertebral body. Radiology 1989; 172: 219-222

  15. Panow C, Valavanis A. A case of aseptic vertebral necrosis in the context of metastatic lumbar disease. Neuroradiology 2002; 44: 249-252


This is a peer reviewed paper 

Please cite as : Colaris J W : Is A Biopsy Necessary To Diagnose Kümmell’s Disease?

J.Orthopaedics 2007;4(3)e13





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